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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1260_Библиотеки_им_академика_М_И_Перельмана
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VIDEO 5
Segmentectomy IV
Video duration 14 minutes 14 seconds
In this video, we demonstrate an anatomical resection of
segment IV.
OUTLINE
The video is divided into the following parts:
• Port positioning
• Ultrasound
• Mobilization
• Parenchymal transection between the left lateral and the
medial sector
• Lowering of the hilar plate, parenchymal transection
between the left medial and the right anterior sector
• Division of the middle hepatic vein
• Important points.
The port positioning is similar to a left hepatectomy
(Figure v5.1). As we make progress during the parenchy-
mal transection, we will move from position1 to position 2
(Figure v5.2). A good understanding of the anatomy from
the preoperative imaging and intraoperative ultrasound
is essential.
This is a CT 3D reconstruction with the tumors indicated
in purple. Notice the tumor close to the drainage of the
middle hepatic vein into the IVC. Therefore, this segment
IV resection will encompass the middle hepatic vein.
This is an overview of the anatomy. The first step is
thorough examination of the liver to understand the
anatomy and rule out metastases in the future liver remnant. In addition to the superficial metastases you can see
on the surface,we need to account for two more. Thisis the
metastasis located at the drainage of the middle hepatic
vein to the IVC (Figure v5.3).It is important to have a good
understanding of the drainage of the middle hepatic vein
and right hepatic vein into the IVC (Figure v5.4). The last
Figure v5.1 The port positioning for a segmentectomy IV is similar to a left hepatectomy. As we make progress during the parenchy-
mal transection, we will move from position 1 to position 2.
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
369
370 Video 5
Figure v5.2 As we make progress during the parenchymal transection, we will move from position 1 to position 2. Position 2 is used
for the dissection at the level of the hepatic venous confluence.
Figure v5.3 This is the metastasis located at the drainage of the MHV to the IVC.
metastasis we need to account for is the one abutting the
middle hepatic vein between segments IVb and V (Figure
v5.5). For correlation, this is an image from the 3D
reconstruction shown earlier (Figure v5.6).
In the next section, we show you the optimization of
working conditions for the parenchymal transection, which
includes mobilization and retraction of the liver as well as
preparation to perform a Pringle maneuver. In the first step,
Segmentectomy IV 371
Figure v5.4 It is important to have a good understanding of the drainage of the MHV and RHV into the IVC.
Figure v5.5 The last metastasis we need to account for is the one abutting the MHV between segments IVb and V.
372 Video 5
Figure v5.6 Three-dimensional vascular reconstruction of the patient’s anatomy with tumor location. Notice the tumor abutting the
MHV at its drainage into the IVC.
we divide the cystic duct, leaving the gallbladder attached to
the liver. We will use it for retraction. Using an endoclosure
device, we pass an Ethibond suture around the ligamentum
teres for retraction. The falciform ligament, however, is left
attached which also helps with retraction. For possible later
Pringle maneuver, we pass an umbilical tape around the
porta. Next, we divide the parenchymal bridge between
segments III and IVb. This will facilitate exposure of the
portal structures.
Once the parenchymal bridge has been entirely opened,
we approach the left portal pedicle. Therefore, we switch
to scissors for more careful dissection. Next, we lower the
hilar plate. Using scissors, we open the most medial part of
the hepatoduodenal ligament. Careful dissection is necessary to avoid injury to the portalstructures going to the left
of the liver. While lowering the hilar plate, we expose the
drainage vein to segment V. Placing a hemostatic agent
into the crevice will give us excellent visualization of the
portal structures during our dissection.
The next step is parenchymal transection between the left
lateral and left medial sectors. We continue our dissection
past the ligamentum teres along the falciform ligament. At
this point, we control the portal branch to segment IVb. The
portal branch is clipped and divided. The portal branches to
segment IVa will be controlled later once the parenchymal
line has been deepened. Next, we control the drainage vein
to segment IVb; after dissectingitoutfully,itwillbecutand
divided. In order to gain more mobility for retraction, we
open up the coronary ligament further. With this added
mobility, we can expose our transection line further and
continue our dissection. Now that we have good exposure
to the main left portal pedicle, we can clip and divide the
portal pedicle to segment IVa. The portal branches are
dissected out, clipped, and divided.
As mentioned earlier, the portal branches to segment IVb
have already been controlled. However, we know from
preoperative imaging, as well as intraoperative ultrasound,
that there is an additional portal branch to segment IVa. By
opening up the liver further, we are exposing that branch.
Now the portal branch to segment IVa is fully exposed. We
confirm on ultrasound that this is indeed a branch to
segment IVa. Placing a clamp on the branch helps to identify
it on ultrasound; shaking the clamp is helpful.Also clamping
and unclamping the branch on Doppler flow mode helps to
identify the branch. After we confirm that this is the branch
to segment IVa, it can be divided using thermofusion. The
left border of segment IV is divided by the left hepatic vein. It
is exposed here and we follow its drainage into the IVC. This
dissection here is critical. We expose the confluence of the
middle hepatic vein and left hepatic vein and their drainage
into the IVC. The middle hepatic vein defines the border of
segment IV. We dissect out the coronary ligament further to
get better exposure of the middle hepatic vein drainage in
the IVC. This will help us at the completion of the dissection
Segmentectomy IV 373
at the middle hepatic vein. After completion of the dissection between the left lateral segment and the medial sector,
we have excellent demarcation of segment IV.
The next step is parenchymal transection along the middle
hepatic vein. The gallbladder is used for retraction. Here, we
are exposing the drainage vein to segment V which is clipped
and divided. With superior traction on the specimen, we
start to draw in the two transection lines. We continue the
transection between segment IV and VIII. With this mobility
of the specimen, we can proceed with dividing the middle
hepatic vein. We confirm with the laparoscopic DeBakey
clamp that we have good access in case of stapler misfiring.
Now the middle hepatic vein can be staple divided.
We continue our parenchymal transection along the
middle hepatic vein between segments IVa and VIII. However, we need to identify the drainage vein to segment VIII
prior to completing our dissection. Now we have identified
the drainage vein to segment VIII, from which we have some
bleeding. The bleeding is controlled with a compress. As we
have better exposure of the branch, we can place a vascular
Anatomy figures
clamp. We expose the drainage vein to segment VIII further
for later staple division. The segment VIII drainage vein is
staple divided. Now the specimen is completely mobile and
can be removed using an endoscopic retriever bag.
We complete the case by placing a collagenous sponge
coated with fibrinogen and thrombin on the transection
surface. Prior to completing the case, we inspect the
middle hepatic vein staple line.
IMPORTANT POINTS
• Ensure that you have an optimal set-up prior to the
parenchymal transection. This includes a set-up for
retraction and Pringle maneuver.
• Intraoperative ultrasound is crucial.
• Leaving the falciform ligament as well as the gallbladder
attached will help with retraction.
• Use anatomical landmarks so that you do not get lost
during the parenchymal transection. Also, have an alternative resection plan in mind.
Figure v5.7 Critical anatomy for a resection of segment IV. The resection follows the main left and right PP. The key is that all short
branches off the main PP are controlled to prevent bile leaks and injuries to the main PP. P4b and P4a often have a variable
anatomy, with several portal branches feeding each segment. The intermediate branch of the HA is also controlled early. It can come
off the LHA, the RHA, or between the RHA and LHA.
374 Video 5
Figure v5.8 Relationship of portal structures and RHV and MHV. Dominant branches, especially those off the MHV, need to be
controlled at the beginning of the parenchymal transection.
Figure v5.9 View along the parenchymal transection plane. If the MHV is included in the specimen, it is typically exposed during the
parenchymal transection. Care needs to be taken to avoid injury to the LHV when dividing the MHV at its common drainage with
the LHV into the IVC.
VIDEO 6
Segmentectomy IVa
Video duration 8 minutes 33 seconds
In this video, we will show you a resection of segment IVa.
OUTLINE
The video is divided into the following parts:
• Port positioning
• Transection between segments IVa and II
• Transection between segments IVa and IVb
• Exposure of the middle hepatic vein
• Transection between segments IVa and VIII
• Important points.
Figure v6.1 demonstrates the port positioning which is
slightly higher than during resectionof segment IVb. Next,
we will show the transectionof the medial borderbetween
segmentsIVa andII. Theumbilical fissure hasbeen opened
(see Video 7) and we are dissecting between segments III
and IVb. The aim of this dissectionis to expose the mainleft
portal pedicle which gives out branches to segments IVa
and b. In order to avoid an injury to the main portal
pedicle, this dissection is carried out with scissors.
Here the left main portal pedicle has been exposed with
its branches to segment IVa, II, and III (Figure v6.2). One
of the branches to segment IVa is dissected out, clipped,
and divided. We now continue our transection along the
falciform ligament which has been divided earlier; this
defines the border between segments IVa and II. We are
now approaching the IVC where we will expose the
drainage of the middle hepatic vein into the IVC. This
Figure v6.1 The port positioning for a segmentectomy 4a is slightly higher than that for a resection of segment IVb.
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
375
376 Video 6
Figure v6.2 Here the left main PP has been exposed with its branches to segment IVa, II, and III.
dissection is carried out with a blunt suction tip or with
scissors. Here, the drainage of the middle hepatic vein into
the IVC has been exposed (Figure v6.3).
Next, we will showthe transection between segments IVa
and b. We divide the liver capsule along the line of the main
left portal pedicle. At the bottom of the parenchymal transection line, you can see the main left portal pedicle. It is
critical not to injure it. The main left portal pedicle is a good
landmark to definetheinferiorborderofsegmentIVa
(Figure v6.4). Slightly more proximal to the portal branch
of segment IVa, that has already been controlled, is an
additional one that will be controlled with a clip and divided.
Next, we will dissect out and follow the middle hepatic
vein which defines the lateral border of our dissection. Here,
we are approaching the distal part of the middle hepatic vein.
The middle hepatic vein comes into view (Figure v6.5).
Figure v6.3 Drainage of the MHV into the IVC. Avoidance of a venous injury at this step is critical.
Figure v6.4 The main LPP is a good landmark to define the inferior border of segment IVa.
Segmentectomy IVa 377
Using ultrasound, we identify the course of the middle
hepatic vein between segments IVa and VIII. We open
thecapsulealongthecourseofthemiddlehepaticvein.
This parenchymal transection line will join with the earlier
parenchymal transection between segments II and IVa. This
will occur at the level of the hepatic venous confluence.
We deepen the transection until the middle hepatic vein
is reached. With superior traction on the specimen, we join
the parenchymal transection along the left portal pedicle,
seen in the inferior part of the picture, and the middle
hepatic vein. As you can see, we are completely exposing
the medial aspect of the middle hepatic vein. Minor bleeding
from small holes in the middle hepatic vein is controlled
with bipolar forceps. At the confluence of the left and
middle hepatic veins, the drainage vein to segment IVa is
controlled (Figure v6.6). At this step, segment IVa is completely detached. This showstheresectioncavityatthe
completion of the case with an exposed middle hepatic vein.
Figure v6.5 Here the distal part of the MHV has been exposed.
378 Video 6
Figure v6.6 At the confluence of the LHV and MHV the drainage vein to segment IVa (VIVa) is controlled.
IMPORTANT POINTS
• Resection of segment IVa begins with opening the umbilical fissure.
• Be familiar the anatomical variants of the segment IV
portal pedicle.
• Avoid injury to the left main portal pedicle and follow the
middle hepatic vein to its drainage into the IVC.
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